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Primary surgical treatment for
early epithelial ovarian cancer
Francesco Fanfani
Department of Medicine and Aging Sciences
University "G. d'Annunzio” Chieti-Pescara, Italy
[email protected]
Agenda
Epidemiology and Prognosis in EOC
Type of approach in EOC
Role of lymphadenectomy in EOC
SLN in EOC
Importance of restaging
Tumor rupture during LPS
The role of dedicated pathologist
Fertility Sparing Surgery
Early Stage Ovarian Cancer
Some considerations..
5Y Relative-survival
Early stage EOC
have
good
prognosis
(around 90%)
MAIN ISSUES
 Minimally Invasive Approach
 Fertility sparing surgery
Ovarian cancer may
appear during their
reproductive
age
(around 15% of cases)
 NCCN-GL recommend appropriate surgical staging, followed by
adjuvant CT.
 Comprehensive surgical staging is recommended and includes
WC, peritoneal biopsies, BSO, TH, omentectomy, Pe and Ao LFN.
 In selected patients who want to preserve fertility, USO can be
considered.
 There is no mention of the type to approach to use.
 Adjuvant CT is based on the pathologic findings of the surgical
specimen. The current NCCN guidelines recommend adjuvant CT
in patients with Stage IA G3, IB G3, or any grade of IC.
No survival benefit from Lymphadenectomy
Positive LNs according with tumor histotype:
Serous≈25%
Mucinous=<1%
Endometrioid/Clear cell≈10%
Positive LNs according with tumor grade:
G1/2s≈2%
G3≈23%
Positive LNs according with CA125:
<35UI/ml<1%
>35 UI/ml≈22%
Surgical staging could be
tailored according to clinicopathological risk factors
Recurrence free survival
Disease specific survival
MINIMALLY INVASIVE SURGERY IN GYO
....and where we are now
ESMO
Endometrial
cancer
MIS is superior to
standard laparotomy in
early stage disease
NCCN 2015
MIS recommended in
early stage disease
Level Evidence=1
Cervical cancer
-
MIS or laparotomy can both used in
early stage disease
Level Evidence=III
Ovarian cancer
-
• MIS can be used for surgical staging
in early stage disease
Level Evidence=IIB
• MIS can be used to decide upfront
treatment in advanced stage
Level Evidence=III
- It is retrospective study includes a large
number of homologous patients with
the same histology who underwent a
similar surgical procedure and received
platinum-based CT.
- This study revealed no significant
difference in clinical outcomes between
groups with early and late start of CT
within 6 weeks.
2005
No differences were observed in term of harvested lymph nodes, and
omental size between the two groups
Surgical outcomes and complication rate were in favour of the LPS group
2009
LPS staging appears to be feasible and comprehensive without
compromising survival when performed by GYO experienced with
advanced LPS
300 pts
•
•
•
Multi-istitutional cohort
study.
300 apparently early EOC
staged by LPS from 2000
to 2014:Group 1: Primary
treatment; Group2I:
restaging
Median FU 22 months
75% of patients
underwent Pe/Ao LFN
Conversions rate was
higher in Group 1 versus
14
Group 2
UPSTAGED PATIENTS:
Group 1: 24.9%
(lnf 10%, peritonal 14.8%)
Group 2: 7.4%
(lnf 4.7%, peritoneal 2.7%)
The 3-year DFS and OS rates were 85.1%, and 93.6%, respectively in the whole series
and were comparable to those reported in the literature
15
Apparent early EOC can be safely
managed with LPS in referral Centers
•The 3-yr DFS and OS were 85% and 94% in the whole series
2015
Int J Gynecol Cancer
406 SGO members responded to the survey
Procedure most
commonly performed
100
80
Adnexal
masses
Endometrial
cancer
2012
60
Cervical
Cancer
40
Ovarian
Cancer
20
Endometrial
cancer
0
2007
2012
Between 2007 and 2012, there were significant increases in the
proportions of respondents who thought MIS was appropriate for
staging of EC, OC and CC
Perspectives and key-issues
SLN in EOC
Importance of restaging
Tumor rupture during LPS
The role of dedicated pathologist
Fertility Sparing Surgery
PERSONALIZING SURGICAL STAGING:
Tailoring radicality with SNB
Sentinel Node in ovarian cancer (SONAR)
(NCT01734746)
 Maastricht University Medical Centre, Maastrich, The Netherlands
Phase I, single-arm, feasibility/safety study/20 pts
LPS probes
Women with highly suspicious ovarian malignancy receiving laparotomy
available!!!
Injection of both blu-dye and technetium in the ligamentum ovarii proprium (median
side) and the ligamentum infundibulo-pelvicum (lateral side). After 15 minutes the
ovarian mass is removed, retroperitonal space is opened , SN is detected and removed
Primary end-point: accuracy of SNB technique
Secondary end-poin: anatomical distribution of metastatic lymph nodes
Suspected pelvic mass
planned for surgery
SELLY
UCSC RANDOMIZED PROTOCOL
•
•
•
CT scan or MRI
Pelvic US
Ca125
SENTINEL LYMPH NODE
detection and removal
ISB
IC-G
Removal of the pelvic mass and
sending to frozen section
Frozen section: benign
Stop surgery
Excluded from the study
Frozen section: malignant
Surgical Staging
(radical1 or conservative2)
Included in the study
1 Total histeroctomy, salpingoopherectomy bilateral, lomboaortic lymphadenectomy, total omentectomy, peritoneal biopsies, peritoneal washing
2
Monolateral adnexectomy, controlater ovarian biopsy, lomboaortic lymphadenectomy, total omentectomy, peritoneal, biopsies, peritoneal washing
RESTAGING
EOC
Radiological staging
Revision of histological samples (dualistic model)
COUNSELLING
• Restaging ip/lfn
• SOM vs. Conventional surgery
• MIS
MIS re-staging of apparent early EOC
should be performed when possible
Advantages
 Early discharge and more rapid onset of CT
 Less adhesions that can impair fertility
Disadvantages
 Longer operative time
 Does not allow thorough inspection of posterior diaphragm behind the liver or
the high part of left hemidiaphragm
 Risk of spillage
 Port site mts*
* (1.96% according to Zivanivic et al Gynecol Oncol 2008)
Time delay influences the stage of disease and
survival time.
Strict preoperative protocols should be in place to
ensure that an absolute minimum number of patients
with OC have a first preliminary and then a second
definitive surgery
DFS
OS
p<0.05
p=0.2
An accurate frozen
section for ovarian
tumors is of great value in
preventing under- and
over-treatments
Fertility-sparing:
Relevance of the problem
• OC: 10-20 cases per 100,000 women/y
• Nearly 80% are advanced stage
14% of women with EOC are
< 40 years old
 The recent increase in early gynecologic checkups using
ultrasonography has increased the frequency of EOC diagnoses at early stages
 Vital statistics reports from Europe state a strong tendency of
continued first birth postponement  diagnosis of EOC during
reproductive years is increasing
 Answer of fertility-sparing surgery (preservation of at least a part of
1 ovary and the uterus).
Available Guidelines for conservative
management of Ovarian cancer
FSS is safe in low risk eEOC. Young patients with high risk eEOC, who wish to preserve their childbearing
potential may benefit from FSS approach.
Pts with high risk disease experienced worse survival outcomes, these survival results are not influenced
by type of surgical approach (FSS vs. RSC).
The opportunity to extend the indication to conservative surgery to women with more advanced disease
is highly controversial and needs further investigations.
Thanks for your attention